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• WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205-6232(209)4683420 <br /> NON-REFUNDABLE PERMIT �J /1�www.sigov.org/ehd EXPIRES I YEAR <br /> FROM DATE ISSUED <br /> JOB ADDRESS ,-V CITYZP �v l`� ' <br /> D <br /> CROSS STREET <br /> LAPN �`�3 d H/0 <br /> 6 s{ PARCEL SIZE <br /> (t LAPA USE APPP/UC(no•NN# <br /> // 7 _O <br /> OWNER NAME PHONE <br /> OWNER ADDRESS t! ' GY/STATEZP 4-51N <br /> � \� <br /> CONTRACTOR �S // PHONE /�,/qy( <br /> CONTRACTOR ADDRESS —7dTY <br /> d I ''����� CIISTATEZP zT <br /> SUBCONTRACTOR/CONSULTANT PHONE <br /> SUBCONTRACTOR/CONSULTANT ADDRESS CITYYfSTTAATTEZP �7 <br /> LICENSE )62-57 -01 0 D-09 Ci Other NUMBER V LSD/ EXPIRATION DATE G <br /> BILLING PARTY: C OWNER C CONTRACTOR 0 SUBCONTRACTOR/CONSULTANT <br /> DoMEsnc WELL SAMPLING:)'General Mineral/Coliform Bacteria(4391)Dibromochloropropane(4392)❑Arsenic(4393) <br /> INTENDED USE Domestic/Private D Irrigation/Agricultural C Industrial Water Quality Monitoring C Soil Sampling/Characterization <br /> Public Water System <br /> I II different Irom Owner Water Syetem Name Contoa Name or Phone Number <br /> TYPE OF WORK 0 New Well eplacement Well Well Alleration/Modification C Other <br /> =Monitoring Well(s) #of wells Soil Banng(s) a of bonngs C Geotechnical sof borings <br /> '7 Out-Of-Service Well C Out-Of-Service Well Renewal 2 Cross-Connection Repair <br /> ew Pump 0 Pump Replacement C Pump Repair -j Raise Well Casing <br /> WELL CONSTRUP6TION <br /> Drilling Method Mud Rotary C Air Rotary C Auger Cable Tool Push Point ❑ Other <br /> Proposed Wel Depth 7117 ft Excavation L—in diameter 'i Open Bottom t,!)Gravel Pack/Gravel Size in diameter <br /> Conductor Casing In diameter / Conductor Casing Depth ft <br /> Well Casing Diameter_in Thickness/Gauge/ASTM Sched G�Z C Steel �1Plastic ^Stainless Steel ❑Other <br /> Grout Seal Depth CJ ft 0 Neat Cement(94 lb bag/S10 gal water) / Sand Cement sack mix(7 pal water <br /> ,*Ientonite(20%solids) 9 Other <br /> Grout Placement Method C Pumped D Free Fall 0 Other D Retardant/Accelerator(name) <br /> PEDESTAL Installed By C Driller ump Contractor 0 Other <br /> Concrete Pedestal❑ Imensions:Width ft Length ft Thick in C Christy Box C Stove Pipe <br /> PUMP ubmersib{e❑Turbine C Other HPPump Sel R Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE ENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION AWS. ff(`1/ttf`j�Oif,G �l�O'=CM <br /> r�, <br /> M.�/� VANC NOTICE REQUf D FOR�IjN/SP TIVNS PLEASE CALL(209)95 69�J <br /> SIGNED y 1 TITLE ✓�y�-�� DATE <br /> 3/v <br /> ��4-441 1 j <br /> t <br /> F YMFNT <br /> AY CF�V�D <br /> a 20?0 <br /> y� J'D E P A R T M E N T U E /1 AI,O 0O <br /> Application Accepted By —/"��` Date S ZL�� Area I `y Employee 10# ,•V�RO^/�ECo(/N�. <br /> Grout InspeU on By Date ❑ SPECIAL Well Permit OI�p�TTq( <br /> Date ❑ WAIVER Received /belt <br /> Pump InspeUion By _ <br /> Soil Boring Inspection By Date Constructed Well Depth h <br /> COMMENTS <br /> PE SCReceived ec Amount Date PermiU Invoice# Well ID# <br /> Codes Info B Cash Remitted rvice Re uest# <br /> L4 K' D, isa <br /> LI 66 i o b n <br /> 41 C -I rCl <br /> WELL IPUMP PERMR <br /> ENO•y00 a/112a/9 <br />